Could the President and Congress Precipitate a Public Health Crisis?

Statements by candidate and then President-Elect Donald Trump, as well as by Republican leaders of both houses of Congress, could, if translated into policy, precipitate a public health crisis. Up to 22 million Americans could lose health care coverage from private insurers and Medicaid that they are receiving under the Affordable Care Act (ACA; Public Law 111-148). The health impact of a potential crisis in insurance coverage could be exacerbated by cutbacks in subsidies for other determinants of population health such as social services, income support, nutrition, housing, and education.

Numerous articles in peer-reviewed journals and reports from prestigious organizations over many years have documented that expanded health service coverage yields measurable improvements in the health status of both individuals and populations. Although the methods of some of these studies have been challenged, widely shared agreement about their findings predicts a pending crisis for public health, a crisis to which hospitals, health systems, clinicians, community health centers, religious groups, and philanthropies may struggle to respond, especially if the extent of their funding becomes uncertain.

EFFECTS ON HEALTH STATUS OF COVERAGE EXPANSIONS

Several recent studies of expansions in health insurance have revealed substantial linkages between coverage and improved health status. The authors of a 2014 quasi-experimental study of changes in mortality in Massachusetts after health care reform concluded that “reform in Massachusetts was associated with a significant decrease in all-cause mortality compared with the control group after access improved.” Moreover, “these changes were larger in counties with lower household incomes and higher pre-reform uninsured rates” and were associated with “significant gains . . . in self-reported health.” The standard “number needed to treat” was “approximately 830 adults gaining health insurance to prevent 1 death per year.”^{1(pp585–586)}

There are also benefits that still must be harvested. In 2015, the authors of an article focusing on the effects of health insurance expansions on adults with hypertension projected that “currently anticipated health insurance expansions would lead to a 5.1% increase in [the] treatment rate among hypertensive patients” and, as a result, would “lead to 111,000 fewer new coronary heart disease events, 63,000 fewer stroke events, and 95,000 fewer [deaths related to cardiovascular disease] by 2050.” They concluded that “federal and state efforts to expand coverage among nonelderly adults could yield significant health benefits . . . and narrow the racial/ethnic disparities in health outcomes for patients with hypertension.”²

The authors of a 2012 review of the literature evaluating expansions in Medicaid coverage over several decades prior to the ACA concluded that these expansions had resulted in a reduction in mortality among adults, infants, and children.³ More recently, many have cited the Oregon Health Study because of its superior randomized controlled methodology and have highlighted the study’s finding that Medicaid addresses the two primary purposes of health insurance: financial protection and improved access to health services.⁴

Although we focus on the implications of ACA repeal for the health of individuals and populations, it is important to recognize that health insurance allows individuals to obtain care when they are sick and in need without becoming impoverished as a result of high medical bills. Indeed, perhaps as a consequence of the peace of mind that insurance affords, the Oregon Health Study also showed a 30% reduction in the rate of depression and a 20% increase in self-reported good health.⁵ Although the study did not reveal any improvements related to specific laboratory tests (e.g., prevalence or diagnosis of hypertension or high cholesterol levels, or the use of medications for these conditions) during an 18-month time frame, its authors’ overall conclusion was that Medicaid improves well-being.⁶

AVERTING A PUBLIC HEALTH CRISIS

These positive results associated with expanded coverage would not necessarily be automatically reversed for all or some of the 22 million people who are at risk for becoming uninsured as a consequence of changes in national health policies. An important reason to avoid such a heroic assumption is that only a small number of relevant studies have been published to date. Moreover, if employment rates rose and wages increased (as a result of various factors), many newly uninsured individuals might gain coverage through their places of work or be able to purchase it themselves. In addition, some of the health risks faced by the newly uninsured could be offset by federal and state policies that subsidize coverage and the uncompensated care provided by hospitals and community health centers.

A NEW CHALLENGE FOR PUBLIC HEALTH

A substantial reduction in coverage would, however, create new problems for public health agencies and professionals. The most difficult of these problems is likely to be meeting the growing demand for preventive, diagnostic, and treatment services from already underfunded public hospitals and clinics. Reductions in coverage would also require substantial changes in community benefit activities designed by health systems, in collaboration with public health agencies, in response to the new 501(r) section of the Internal Revenue Code included in the ACA. New federal and state policies could, moreover, curtail the many new state programs, established under federal waivers, that restructure delivery of care paid for by Medicaid and Medicare to further the “triple aim” of improving access and quality and containing costs.

AN UNUSUAL PUBLIC HEALTH CRISIS

These new problems would create, for the first time in this country since the Great Depression of the 1930s, a public health crisis caused by loss of access to care. Such crises have continued to occur in countries that have been invaded or have experienced violent internal revolutions.

Unlike public health crises caused by outbreaks of infectious disease or the increasing incidence of chronic degenerative diseases, few interventions have evolved to address a sudden loss of access to services to prevent, diagnose, and treat disease and respond to injury. Before the vast expansion of access that began during the Second World War, public health officials in this country confronted numerous crises resulting from loss of access to care during downturns in the economy.

A considerable historical literature documents variation in the success of interventions implemented on these occasions by public officials, individual philanthropists, and charities created by religious and ethnic organizations.⁷ Although care provided by local voluntary organizations was somewhat effective in addressing sudden loss of access, on the whole the volunteer approach resulted in extremely fragmented and unequal access to care. In part because services were not extensive enough, moreover, the response to the loss of access included rationing care by applying criteria based on acuity of symptoms and, disturbingly, on race, ethnicity, and social class.

In summary, although their magnitude and consequences for health status cannot yet be predicted with precision, the health policies advocated by many people prominent in the new administration and in Congress will, if implemented, likely have an adverse impact on the health status of many Americans by reducing or capping spending for health insurance, preventive services, and investments in social conditions that affect population health.